Pediatrician Release Form
Please be advised that a new federal privacy law went into effect on April 21, 2003. It provides more stringent guidelines for the release of even the most basic medical information.
It has been the practice of the Barnard Babysitting Agency to confirm that your child is a patient of the pediatrician you have indicated. No other information is requested other than the attached confirmation, and we do not share this information with others. In lieu of this pediatrician release form, we also accept copies of birth certificates or immunization records. Contracts cannot be processed without this information. Thank you.
Manager, Barnard Babysitting Agency
PLEASE DOWNLOAD AND FILL THIS FORM OUT COMPLETELY AND RETURN IT WITH YOUR CONTRACT AND CHECK TO:
Barnard Babysitting Agency
C/O Office of Career Development
New York, NY 10027